The North of England P&I Association. The Quayside, Newcastle upon Tyne, NE1 3DU, UK Telephone:

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8 ATTACH PHOTOGRAPH HERE LAST NAME FIRST NAME MIDDLE INITIAL SEX AGE DATE OF BIRTH CIVIL STATUS PASSPORT NO. JOB APPLIED FOR MANNING AGENT PRESENT MAILING ADDRESS TEL. NO. HEIGHT(2) WEIGHT(3) PULSE BODY BUILD(4) CHEST:INSP(5) ins m lbs /min SS MS CHEST: EXP ins ins kgs reg irr LS OW ABD GIRTH(6) ins VISUAL ACUITY FAR VISION NEAR VISION COLOUR VISION(7) CLARITY OF SPEECH UNCORREC L R L R TED CORRECTE D L R L R DENTAL CHEST X-RAY PA AP X Ray No. UPPER NEGATIVE BLOOD TYPE: LOWER POSITIVE BLOOD PRESSURE: (14)(20)(21) / FAMILY HISTORY Fathe r Mothe r Broth er/s Sister/ s MEDICAL HISTORY(8) Present Age Present state of health Age at death Cause of death 1. Asthma or wheezing YES NO 12. Nose bleeding YES NO 22. Swelling of feet YES NO 2. Bronchitis YES NO 13. Hearing problems YES NO 23. Fainting attacks YES NO 3. Pleurisy YES NO 14. Rheumatic fever YES NO 24. Migraine YES NO 4. Tuberculosis YES NO 15. High blood pressure YES NO 25. Blackouts YES NO 5. Pneumonia YES NO 16. Heart attack YES NO 26. Fits YES NO 6. Coughed up blood YES NO 17. Chest pain YES NO 27. Epilepsy YES NO 7. Shortness of breath YES NO 18. Palpitations YES NO 28. Muscular weakness YES NO 8. Other chest complaints YES NO 19. Poor circulation YES NO 29. Paralysis YES NO 9. Sinus trouble YES NO 20. Other infections of the heart or 30. Stroke YES NO YES NO 10. Frequent colds YES NO circulatory system 31. T.I.A. YES NO 11. Ear infections YES NO 21. Varicose veins YES NO 32. Tingling YES NO I hereby permit the undersigned physician to furnish such information the company may need pertaining to my health status and other personal medical findings and do hereby release them from any and all legal responsibility by doing so. I also certify that my medical history contained above, is true and any false statements will disqualify me from my employment, benefits and claims. S i g Examiner Candidate Name of employer n a t u r e

9 LAST NAME FIRST NAME MIDDLE INITIAL SYSTEMIC EXAMINATION(9) NORMAL FINDINGS NORMAL FINDINGS 1. Skin YES NO 11. Heart YES NO 2. Head, neck, scalp YES NO 12. Abdomen YES NO 3. Eyes - external YES NO 13. Back YES NO 4. Pupils, YES NO 14. Anus - rectum YES NO 5. Ears YES NO 15. G - U system YES NO 6. Nose - sinuses YES NO 16. Inguinals, genitals YES NO 7. Mouth - throat YES NO 17. Reflexes YES NO 8. Neck, L. N. YES NO 18. Extremities YES NO 9. Chest - breast - YES NO 19. Dental (teeth) YES NO 10. Lungs YES NO 20. Surgical Operations YES NO AUDIOGRAM Right Ear Left Ear Khz JB Khz JB LUNG FUNCTION TESTS FEV 1 FEV 2 PEFR STANDARD EXAMINATION 1 Chest X-Ray (14x17) (10) 2 Complete Blood count (13) 3 Routine Urinalysis (11) 4 FECT (for food handlers) 5 Blood Typing (A, B, O and Rh factor) 6 Dental Check-up 7 Optical Check-up 8 Complete P.E. & History (12)(15)(22) ADDITIONAL EXAMINATION Lipid Profile Others Triglycerides (19) Hba1C (24) Cholesterol (16) HIV 1 & HIV 2 HDL (17) Audiometry LDL (18) 13 Ishihara Liver Profile Pulmonary Function Test SGPT Kidney Function Test Creatinine TPHA or VDRL Screening ECG BUA (Blood Uric Acid) Hepa B Antigen Test Hepa C Stress Test (if applicable) Cardio Profile (if applicable) It is recommended that the seafarer is given anti-malarial injections and instructions for the taking of appropriate medication throughout the term of the contract.

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15 I(name).of(address). understand that I have been issued with a fit to work certificate so that I may take up employment with (name of employer). on the understanding that I will be responsible for taking prescribed medication for the condition of (Name of Clinic).. have carefully explained my condition, and the instructions for the required medication and how this should be administered. I hereby agree to follow these instructions and take responsibility for ensuring the required medication is available during my contract of employment with (name of employer)... Should any complications arise because of my failure to provide and administer the required medication, my employers will not be held responsible. I confirm that I understand all the implications of non-compliance with this undertaking that have been fully explained to me. Signed:. Dated:...